RU2742594C1 - Method for stenting bile ducts stricture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to hepatopesurgery. Papillosfinterotomy or cylinder dilation of the stricture is performed. The diameter and length of the bile duct strings after papillocytomy or cylinder dilation are determined. Two stents are placed in the bile ducts, the diameter of the first stent being not more than 90% of the narrowing diameter and the diameter of the second stent being between 40 and 50% of the narrowing diameter. The length of the larger stent exceeds the length of the stricture and the retroostenic section of the biliary tree by 3.0 cm, the length of the second stent exceeds the length of the first stent by 2.0 cm. The stents are matched by anatomical ratio and shape. First, a larger-diameter stent is installed so that the upper antimigratory petal is located above the upper edge of the stricture, and the lower petal is located in the lumen of the duodenum, the second stent is placed one centimeter further from the beginning of the stricture than the first stent.

EFFECT: method enables increasing the time of effective functioning of bile duct stents, reducing probability of their migration and reducing the frequency of the replacement of stents, thereby reducing the beam load for the patient and, as a result, increasing the safety of the procedure.
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Description

The invention relates to medicine, namely to surgery, and can be used in the treatment of patients with obstructive jaundice.

The syndrome of obstructive jaundice, with its progression, leads to the development of liver failure, cholangiogenic liver abscesses and the death of the patient. Therefore, obstructive jaundice syndrome requires its quickest resolution. Endoscopic interventions are the most promising modern treatment for this syndrome. In this case, either balloon dilatation of the narrowing site is performed, or papillosis-fincterotomy with the location of the narrowing site in the distal common bile duct. These procedures are often completed with the installation of a stent to maintain the effect of the intervention for a longer time, since it is known that strictures of the bile ducts are prone to recurrence. Over time, the lumen of the stent becomes covered with bile salts, and it begins to function. In addition, it is possible to overlap the lumen of the stent (for example, by a stone fragment). All this requires replacement of the stent during the second endoscopic procedure.

There are known works in which it is shown that the installation of 2 stents lengthens the operating time of the stents due to the "wick" effect (Dong Ki Lee, Jae Hoon Jahng Alternative methods in the endoscopic management of difficult commonbileductstones.//DigestiveEndoscopy.- 2010. -22 (suppl. 1) -P.79 -84.). The authors proposed this method for the treatment of pristenosis of the terminal section of the common bile duct.

This stenting method was taken by us as a prototype.

The disadvantages of the prototype are - the authors propose this method of stenting only for narrowing the terminal part of the common bile duct, it is not described how to proceed in the presence of narrowing in other parts of the bile ducts, as well as in the presence of extended strictures. Secondly, it is not described how to select the stent diameter when installing 2 stents. Changing the size of the stents will lead to different severity of the "wick" effect. Thirdly, it is not described how to choose the length of stents when installing 2 stents at the same time. In order to eliminate these disadvantages, a method for stenting the bile duct stricture has been developed.

The method is carried out as follows: a patient with obstructive jaundice is performed a retrograde cholangiography) and a bile duct stricture is diagnosed - its localization, length and degree of narrowing. Then balloon dilation or papillosphinterotomy is performed, after intervention on the stricture, the remaining degree of narrowing and its length are measured. After that, 2 stents are installed: the diameter of the first stent should be no more than 90% of the narrowing diameter, and the diameter of the second stent should be 40-50% of the narrowing diameter. The total length of the first stent exceeds the length of the stricture and the retrostenotic portion of the biliary tree by 3.0 cm, the upper anti-migration lobe is located above the upper edge of the stricture, and the lower lobe is located in the duodenal lumen. The second stent of a smaller diameter exceeds the length of the first stent by 2.0 cm. The stents are selected with the same anatomical ratio and shape (both straight or both with a central curvature). The larger stent is placed first. A stent with a smaller diameter is placed 1 cm further from the beginning of the stricture than the first stent.

This method optimizes the flow of bile along the stents, reduces the turbulence of the bile flow, minimizes the likelihood of stent migration and prevents the lumen of the stent from overlapping with a larger diameter, such as a stone fragment.

Example. Patient N .. 68 years old, was admitted to the surgical department with complaints of yellowness of the skin. Previously, he was operated - 2 years ago, cholecystectomy was performed. In the biochemical analysis of blood, an increase in bilirubin to 215.3 μmol / L was noted due to the direct fraction.

Endoscopic cholangiography was performed, which diagnosed the stricture of the common bile duct from / 3 to 4 mm with a length of 1 cm. The bile ducts were dilated proximal to the narrowing. Balloon dilatation of the stricture zone was performed. On repeated cholangiography, the diameter of the common bile duct in the stricture zone was 6 mm, 1 cm long. 2 stents were installed: 12 Fr 9 cm long and 10 Fr 11 cm long. The 10 Fr stent was installed 1 cm proximal to the 10 Fr stent.

The postoperative period was uneventful. Total bilirubin dropped to 19.3 μmol / L. The patient was discharged in satisfactory condition. The patient was examined after 4 months. No complaints. There was no recurrence of jaundice during this period.

The developed method of bile duct stenting was applied by us in 23 patients with obstructive jaundice. In all patients, the obstructive jaundice syndrome was stopped, there was no stent migration, and the duration of stent functioning was achieved from 5 to 6 months.

Thus, the proposed method allows to increase the time of effective functioning of bile duct stents, minimizes the likelihood of stent migration, facilitates the provision of a second stent and reduces the frequency of stent replacement, which leads to a decrease in the economic costs of treating such patients and a decrease in radiation exposure for the patient and, as a consequence, increase the safety of the procedure.

Claims (1)

A method of stenting a bile duct stricture, including: contrasting the bile ducts, papillosphinterotomy or balloon dilatation of the stricture, determining the diameter and length of the bile duct stricture after papillosphinterotomy or balloon dilatation, installing 2 stents into the bile ducts, characterized in that the diameter of the first stent should be no more than 90 % of the narrowing diameter, the diameter of the second stent should be 40-50% of the narrowing diameter, the length of the larger stent exceeds the length of the stricture and the retrostenotic portion of the biliary tree by 3.0 cm, the length of the second stent exceeds the length of the first stent by 2.0 cm, stents are selected with the same anatomical ratio and shape, first a stent of a larger diameter is installed so that the upper anti-migration lobe is located above the upper edge of the stricture, and the lower lobe is located in the lumen of the duodenum, the second stent is installed 1 cm further from the beginning of the stricture by comparison with the first stent.